Dissociative stupor, mutism and amnesia in a young man

Sir,

Patients, presenting with stupor, represent medical emergency and warrant a cascade of exhaustive investigations. Although dissociative disorder is one of the differential diagnoses of stupor, many physicians seldom consider this possibility in men, who lack obvious psychosocial stressors and past history of known psychiatric illnesses. As literature on dissociative stupor is sparse[1], we report a case of a young man, who initially presented to a neurological facility with acute onset stupor.

Mr. SB, a 21-year-old student, was brought unconscious and unresponsive to a neurological emergency department by his parents. He did not have any history of fever, head trauma, seizure, substance abuse, psychosis, or mood disorders. His Glasgow Coma Scale[2] score was eight (E4V1M3). He did not have papilloedema or lymphadenopathy. Systemic examination, including neurological examination for unresponsive patients, was normal. As exhaustive investigations, including metabolic profile, toxicology, cerebrospinal fluid analyses, and neuroimaging, did not detect any abnormality, psychiatric consultation was requested. As he was mute, formal mental status examination (MSE) was not possible. Other catatonic features or hallucinatory behaviours were absent. Despite lacking obvious precipitating stressors, his parents reported past history of two brief episodes of mutism, following academic stressors during his childhood.

Mr. SB was transferred to psychiatric inpatient facility. We monitored his vital signs and ensured appropriate supportive care. After 48h, without any psychotropic medications, he started responding to verbal commands and gradually resumed physical activities. He remained mute for three more days. Then, he started communicating in monosyllables and reported autobiographical memory deficits. Serial MSEs did not reveal any mood or psychotic syndromes. During the third week, he regained his speech and memory, with continued supportive care. His primary therapist conducted individual psychotherapy sessions, emphasizing non-specific and supportive elements[3]. He was encouraged to attend occupational therapy sessions daily. His parents were educated about the psychological model of his illness. Mr. SB expressed conflicts between his academic interests, career preferences and his family's expectations. He was helped to assimilate intra-psychic dynamics and to architect appropriate response patterns. Subsequent sessions focused on enhancing his coping skills and on family interventions. Mr. SB remained asymptomatic and was functioning well for a year after his discharge.

Mr. SB exemplifies mixed dissociative disorder (ICD-10: F44.7) with features of dissociative stupor, mutism, and amnesia. The absence of physical findings, negative neurological workup, and possible secondary gains suggested psychogenic aetiology. Symptom transfer, complete recovery with supportive psychotherapy, and 1 year follow-up data confirmed his diagnosis. We consider dissociative disorder as an important, yet rare, differential diagnosis of stupor. Its prompt diagnosis can avoid unnecessary health expenditure and accelerate clinical recovery.

As contemporary etiological models of dissociative disorders are multifactorial and heterogeneous[4], the management of dissociative disorders should be tailored to individual needs. Establishing therapeutic relationship and emphasizing functional recovery are more essential than probing for underlying psychological conflicts. Psychopharmacological agents are indicated only to treat co-morbid psychiatric syndromes. Family interventions, dealing with primary, secondary and tertiary gains, are helpful[5]. Enhancing coping skills and strengthening personality organization prevent symptom transfer and produce better long-term prognosis.

The association of popular “risk factors” such as gender and past psychiatric morbidity with dissociative disorders is not based on any Indian epidemiological evidence[1]. As dissociative disorders may be more prevalent in community than in hospital settings, we suggest more epidemiological investigations in India to define a reliable model of clinical risk factors for ruling in the diagnosis of dissociative disorders.